VACCINE PREVENTABLE DISEASES IN SAN DIEGO COUNTY...Mar 19, 2019 · 65+ 342 87 68 97 65 70 14 25 58...

VACCINE PREVENTABLE DISEASES IN SAN DIEGO COUNTY

Eric McDonald, MD, MPH, FACEP Medical Director, Epidemiology & Immunization Services

Public Health Services, County of San Diego Health and Human Services

BSPC Meeting

19 March 2019

Image Credit: CDC

TOPICS

Influenza

Mumps

Hepatitis A

Pertussis

Varicella

Measles

INFLUENZA

Image Credit: CDC

Source: CDC. Downloaded 3/18/19 from:

https://www.cdc.gov/flu/weekly/usmap.htm

2018-19 Influenza Season Week 10 ending March 9, 2019

Weekly Influenza Activity Estimates

Reported by State and Territorial Epidemiologists





https://www.cdc.gov/flu/weekly/index.htm


Influenza-Like Illness (ILI) Activity Level Indicator

Determined by Data Reported to ILINet





Dominant Influenza Strain by HHSA Region

Map prepared on 3/18/19 using data from CDC website


and software on: http://diymaps.net/

- H1N1

- H3N2

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1


http://diymaps.net/

6,660

47 DEATHS

CASES

CURRENT UPDATE Reported Since July 1, 2018

17 Preliminary Results as of 3/13/19

Data Source: Reported Influenza Case Reports

Prepared by County of San Diego, Health & Human Services Agency,

Public Health Services, Epidemiology and Immunization Services Branch

OUTBREAKS

http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_01.pdf

INFLUENZA SURVEILLANCE UPDATE, 2018-19 YTD

Preliminary Results as of 3/13/19




Week 10 Week 9

Total To

Date Week 10

Total To

Date Week 10

Total To

Date

All influenza detections reported (rapid or PCR) 564 618 6,660 621 18,758 458 9,484

Percent of emergency department visits for ILI 5% 6% 5% 5%

Percent of deaths registered with pneumonia and/or influenza 5% 6% 9% 10%

Number of influenza-related deaths reported^ 2 3 47 13 301 12 137Influenza season is July 1 - June 30, Weeks 27-26. Total deaths reported in prior seasons: 342 in 2017-18, 87 in 2016-17, and 68 in 2015-16.* Previous weeks case counts or percentages may change due to delayed processing or reporting.** Includes FYs 2015-16, 2016-17, and 2017-18.

Current FY deaths are shown by week of report; by week of death for prior FYs.

Indicator

2018-19 Season 2017-18 Season

Prior 3-Year

Average**

Table 1. Influenza Surveillance Indicators.






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Figure 5. Cumulative Influenza Case Reports by Episode Week & Season.

2018-19 2017-18 2016-17 2015-16 2014-15 2013-14

2012-13 2011-12 2010-11 2009-10 2008-09

2018-19

week 10






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Figure 3. San Diego County Influenza Detections by Type and Week of Report, 2018-19 FYTD (N=6,660).

Influenza A Influenza A(H1N1)pdm09 Influenza A(H3) Influenza B Influenza B/Victoria Influenza B/Yamagata Influenza A/B







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Figure 6. Percent of San Diego County Emergency Department Visits for Influenza-like Illness by Week and Season Compared to

5-Year Baseline & Upper 95% Threshold Values (Serfling Method).

ILI% Baseline Upper 95% Threshold

2013-14 2014-15 2015-16 2016-17 2017-18 2018-19







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Figure 7. Percent of San Diego County Deaths Registered with Pneumonia and/or Influenza by Week and Season Compared to Prior

5-Year Baseline & Upper 95% Threshold Values (Serfling Method).

%P&I Deaths Baseline Upper 95% Threshold

2013-14 2014-15 2015-16 2016-17 2017-18 2018-19







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Figure 9. Influenza Deaths by Age and Season.

<1 yr

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Data Source: San Diego Immunization Registry



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Figure 10. Number of Influenza Vaccinations Administered* by Week and Season.

2014-2015 2015-2016 2016-2017 2017-2018 2018-2019




Data Source: San Diego Immunization Registry



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Week Number

Figure 11. Cumulative Number of Influenza Vaccinations Administered* by Week and Season.

2014-2015 2015-2016 2016 - 2017 2017 - 2018 2018 - 2019

2014-2015 Total: 258,724

2015-2016 Total: 526,5522016-2017 Total: 601,156

2017-2018 Total: 770,0582018-2019 Total: 913,465


Data through 3/17/19.

Source: Rady Children’s Hospital San Diego weekly pathogens report.

INFLUENZA

WHAT CAN YOU DO?

Consider testing for novel influenza in patients with travel history,

avian or swine contacts

Remember influenza causes disease year-round in San Diego

Report ALL positive flu cases to Epidemiology Program

Sign up for Flu Watch

(EISB (619) 692-8499 or [email protected])

Promote early immunization of staff to be consistent with health

officer order “vaccinate or mask” Nov 1- March 31 (likely to extend!)

Promote flu immunizations to patients, especially those at risk for

increased morbidity

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 3/15/19

MUMPS

Image Credit: CDPH

Mumps - an acute viral illness caused by an RNA virus

in the Paramyxoviridae family - the only cause of

epidemic parotitis.

Parotitis – especially sporadic cases – may be due to

viruses other than mumps.

Parotitis can also be caused by Epstein-Barr virus

Human herpesvirus B6 (the cause of roseola)

Cytomegalovirus

Parainfluenza virus types 1 and 3

Influenza A virus

Coxsackieviruses and other enteroviruses

Lymphocytic choriomeningitis virus

Human immunodeficiency virus

Staphylococcus aureus

Nontuberculous Mycobacterium

MUMPS

Prodromal symptoms are nonspecific, may include myalgia, anorexia,

malaise, headache and low-grade fever.

Unilateral or bilateral swelling of one or more salivary glands, usually the

parotid glands (parotitis), which occurs in 30%-40% of infected persons.

Parotitis tends to occur within the first 2 days and may be first noted as

earache and tenderness on palpation of the angle of the jaw.

Symptoms tend to decrease after 1 week and usually resolve after 10 days.

40-50% may only have nonspecific or respiratory symptoms.

Up to 20% are asymptomatic.

MUMPS - SYMPTOMS

Orchitis (testicular swelling) is a common complication and may

occur in as many as 50% of postpubertal males.

Central nervous system (CNS) involvement is common but

fewer than 10% have symptoms of CNS infection.

Other rare complications include arthritis, mastitis,

glomerulonephritis, myocarditis, endocardial fibroelastosis,

thrombocytopenia, cerebellar ataxis, transverse myelitis,

ascending polyradiculititis, pancreatitits, oophoritis, and hearing

impairment.

Mumps during the first trimester is associated with an increased

rate of spontaneous abortion, but although mumps virus can cross

the placenta, there is no evidence that this results in congenital

malformation.

MUMPS - COMPLICATIONS

Mumps exposure

Unprotected face-to-face (<3 feet) contact with an infectious person

for at least 5 minutes.

Incubation period

Usually 16 to 18 days, but cases may occur 12 to 25 days after

exposure.

Period of communicability

Communicability is probably highest from 2 days before to 5 days

after onset of parotitis; mumps virus has been isolated in saliva from

7 days before through 9 days after onset of swelling.

MUMPS - EXPOSURE

Live-attenuated mumps vaccine is given as part of measles, mumps

and rubella (MMR) vaccine in the U.S.

Post-licensure data estimate the effectiveness of 1 dose of mumps

vaccine at approximately 80% (64%-95%) and two doses at 90%

(88%-90%).

In recent large outbreaks, mumps infections have occurred in many

persons with a history of 2 doses of MMR

IMMUNIZATION

LAB TESTING

Acute mumps infection can be laboratory confirmed by: the presence of serum mumps IgM,

a significant rise in IgG antibody titer in acute- and convalescent-phase

serum specimens,

positive mumps virus culture, or

detection of virus from a buccal specimen by reverse transcriptase

polymerase chain reaction (RT-PCR).

Serologically confirming mumps in an immunized person may be

challenging : IgM response may be absent or short lived

studies have shown that individuals with detectable mumps IgG titers

have still developed mumps infection.

LAB TESTING

Unimmunized: buccal specimen & acute blood specimen should be

collected; a convalescent specimen may be requested.

Immunized: buccal specimen should be collected; acute and

convalescent blood specimens may also be submitted for IgM testing

and/or detection of IgG rise. Collection of a buccal specimen within 1

to 3 days of parotitis onset is optimal, however virus may be detected

for up to 9 days after parotitis onset.

Status unknown: buccal & blood specimens should be submitted.

Immunization status of the patient should be clearly indicated on the

laboratory submittal form.

Outbreak: buccal specimen is the preferred specimen for testing.

Neither mumps vaccine nor immune globulin (IG) is effective

for mumps postexposure prophylaxis.

However, MMR vaccination of exposed persons who have

had less than two doses of mumps containing vaccine is

recommended unless otherwise contraindicated, because if

the current exposure does not cause infection, vaccination

should induce protection against subsequent exposure(s) to

mumps, measles or rubella.

Third MMR booster for those with basic series in

college/university outbreaks – useful in outbreak situation

MUMPS POSTEXPOSURE PROPHYLAXIS ?

MUMPS - US


https://www.cdc.gov/mumps/outbreaks.html

N = 151




MUMPS - US



* Case count is preliminary and subject to change.

**Cases as of February 28, 2019. Case count is preliminary and subject to change.




https://www.cdc.gov/mumps/images/outbreaks-graph.png

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*2019

Mumps Cases, San Diego County 1993-2019*

* 2019 data are year to date.

Prepared by the County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services Branch, 3/1/19

MUMPS – MEXICO 2019

Source: Secretaría de Salud. Map prepared on 3/18/19 using data from:

https://www.gob.mx/cms/uploads/attachment/file/443225/sem08.pdf


38 33

79

31

275

112

Total reported

in Mexico = 1,419

through 3/2/19

Total reported

in 6 Mexican border

states = 568

(40.0% of total)



http://diymaps.net/

http://diymaps.net/

http://diymaps.net/

MUMPS – MEXICO 2018


https://www.gob.mx/salud/documentos/_-boletinepidemiologico-sistema-nacional-de-vigilancia-epidemiologica-

sistema-unico-de-informacion and software on: http://diymaps.net/

362 430

1,068

153

917

934

Total reported

in Mexico = 8,818

Total reported

in 6 Mexican border

states = 3,864

(43.8% of total)

https://www.gob.mx/salud/documentos/_-boletinepidemiologico-sistema-nacional-de-vigilancia-epidemiologica-sistema-unico-de-informacion





















http://diymaps.net/

http://diymaps.net/

http://diymaps.net/

2013 2014 2015 2016 2017 2018 2019*

Total in Mexico 4,193 4,132 3,367 3,570 4,585 8,818 1,419

Baja California 258 315 220 200 285 362 38

Sonora 167 111 140 181 222 430 33

Chihuahua 256 398 232 248 355 1,068 79

Coahuila 61 79 48 42 202 153 31

Nuevo Leon 281 273 194 224 384 917 275

Tamaulipas 204 171 160 202 335 934 112

Total Border States Percent of Mexico Cases

1,227 29.2%

1,347 32.5%

994 29.5%

1,097 30.7%

1,783 38.8%

3,864 43.8%

568 40.0%

INFECTIOUS PAROTITIS (MUMPS) MEXICO, 2013-2019*

* 2019 data through Epidemiology Week 10, ending 3/2/19

Source: Secretaría de Salud. Data from reports accessed 3/18/19 at: https://www.gob.mx/salud/acciones-y-programas/direccion-general-de-epidemiologia-boletin-epidemiologico

https://www.gob.mx/salud/acciones-y-programas/direccion-general-de-epidemiologia-boletin-epidemiologico

















MUMPS

WHAT CAN YOU DO?

Consider mumps in patients with parotitis, especially in college-

age individuals and international travelers

A correctly obtained buccal specimen for PCR testing is the best

test for mumps – contact the Epidemiology Program for timely

assistance

Be aware of mumps outbreaks in other countries (Honduras,

some Mexican states, Nepal, China, Japan, etc)

All international travelers should have two doses of MMR

Sign up for Monthly Communicable Disease Reports

(EISB (619) 692-8499 or [email protected])

HEPATITIS A

Image Credit: CDC

Primarily transmitted via the fecal-oral route

Incubation period ranges from 15 to 50 days

(mean 28 days)

Period of communicability from two weeks before

through one week after the onset of jaundice or

elevation of liver enzymes

Virus viable outside body for months, depending

on environmental conditions

HEPATITIS A OVERVIEW

HAV virus inactivated by:

Heating to >185˚ F (>85˚ C) for one minute

Routine water chlorination

1:100 dilution of household bleach to water on surfaces

Quaternary ammonium formulations with HCl

2% glutaraldehyde

Alcohol-based hand sanitizer not effective, need

soap and running water

Vaccination with the full, 2-dose series of Hepatitis A

virus vaccine is the best way to prevent infection

Reference: Mbithi JN, Springthorpe VS, Sattar SA. Appl Environ Microbiol. 1990;56(11):3601-4.

HEPATITIS A OVERVIEW

http://aem.asm.org/content/56/11/3601.full.pdf+html






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Hepatitis A Cases, San Diego County 1994 - 2016

Vaccine introduced

Routine vaccination for children in high-incidence states

(including California)

Routine vaccination for all U.S. children

HEPATITIS A, SAN DIEGO

40

592 confirmed outbreak cases from 11/22/16 thru 10/18/18

407 (68%) hospitalizations, 20 (3.4%) deaths

404 (68%) male (14 MSM), 188 (32%) female

Age range 5-87 (median 43.0)

Suspected Exposure Type

201 (34%) homeless and illicit drug use

91(15%) homeless only

79 (13%) illicit drug use only

167 (28%) neither

54 (9%) unknown

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Emergency Declared

1/23/18

Public Health

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Undeclared 10/18/18

Outbreak

Declared Over

| 2017

Onset Week Data as of 10/18/18

2016 | 2018 N = 6 N = 571 N = 15

Outbreak-associated Hepatitis A Cases by Onset Week

San Diego County Residents, 11/1/2016 – 10/18/2018*, N = 592

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Outbreak-Associated Hepatitis A Cases & Vaccinations by Month, November 2016 through December 2018

Confirmed/Probable Cases Pre Response Vaccinations Response Vaccinations


Cases Vaccinations

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Hepatitis A Cases, San Diego County 1994 - 2018

Vaccine introduced

Routine vaccination for children in high-incidence states

(including California)

Routine vaccination for all U.S. children


Co-infections

81/474 (17.1%) with hepatitis C

25/474 (5.1%) with hepatitis B

20 (3.4%) cases diagnosed in jails

15 primary, 5 secondary

Sensitive occupations

24 food handlers (1 secondary case ID’ed)

7 healthcare workers (1 secondary case ID’ed)

70 non-outbreak CSTE HAV cases

(not included in outbreak count)

45


Based on the San Diego outbreak experience, persons

experiencing homelessness had:

risk for HAV: aOR = 3.1 (95%CI 1.4-7.4)

risk for HAV hospitalization: aOR = 3.8 (95% CI 2.2–6.6)

risk of death from HAV: aOR = 3.9 (95% CI 1.1–17)

CDC recommends that persons experiencing

homelessness get vaccinated against HAV

(See MMWR article)

https://www.cdc.gov/mmwr/volumes/68/wr/mm6806a6.htm?s_cid=mm6806a6_e

Vaccinate

Sanitize/hygiene

Educate

PUBLIC HEALTH STRATEGY

www.sdepi.org

HEPATITIS A – UNITED STATES

Map prepared on 3/4/19 using data from state department of health websites


* 2 separate outbreaks

318

Ontario, CA:

126 cases

912

1,889

2,386 1,089

4,229

945

736

72

70

290

262

45

13 24+56*

281

709

27

http://diymaps.net/

HEPATITIS A

WHAT CAN YOU DO?

Vaccinate children and ADULTS according to ACIP guidelines

Report suspect cases while patients are still at the medical

facility

Do not discharge a suspect or confirmed HAV case unless they

have shelter and a restroom that is not shared

Be aware of continued outbreaks in persons experiencing

homelessness and using illicit drugs

PERTUSSIS

Image Credit: CDC

PERTUSSIS - BASICS

Highly contagious respiratory infection caused by

Bordetella pertussis

Primarily a toxin-mediated disease

Bacteria attach to cilia or respiratory epithelial cells

Cyclic (peaks every 2-5 years)

Most poorly controlled VPD

PERTUSSIS - BASICS

Transmission occurs by close contact via droplets

Very contagious: approximately 90% of

susceptible household contacts become infected

Immunity wanes after vaccination or disease

92-95% of population must be immune to eliminate

transmission

Infants ≤ 1 year of age are most vulnerable

Adolescents & adults transmit disease to infants

PERTUSSIS - BASICS

Incubation Period 7 – 10 days (range 5 – 21 days)

Infectious Period

Persons ≥ 1 year of age = from onset of cold-

like symptoms until after 5 days of treatment or

until 21 days after cough onset if no (or partial)

treatment is given

Infants < 1 year are

considered infectious

for 6 weeks without

treatment

Catarrhal stage 1-2 weeks

Paroxysmal cough stage 1-6 weeks

Convalescence weeks to months

PERTUSSIS - STAGES

PERTUSSIS - SYMPTOMS

Cold-like symptoms

Coryza

Sneezing

Occasional cough

Fever usually absent or minimal

Stage lasts for about 1-2 weeks with cough gradually

becoming more severe

Catarrhal

Stage


Spasms of severe coughing followed by a sudden

deep inspiration

Characteristic “whooping” sound

https://www.soundsofpertussis.com/

Post-tussive vomiting common in all ages

Illness may be milder in previously vaccinated

people

Paroxysmal

Stage

https://www.soundsofpertussis.com/


Coughing, whooping and vomiting decreasing in

frequency and severity

Paroxysms may recur with subsequent respiratory

infections

Classic pertussis is 6-10 weeks, but may last longer

in some people (100 day cough)

Convalescent

Stage

PERTUSSIS – YOUNG INFANTS

Initially mild cough, runny nose, no fever

Develops into serious symptoms:

May gag, gasp or stop breathing (apnea)

Face may turn blue, purple or red (cyanosis)

Post-tussive vomiting

May not have noticeable cough or “whoop”

Seizures

Respiratory distress

Pneumonia

PERTUSSIS - BASICS

Adolescents and adults

Disease is often milder than infants and children

Infection may be asymptomatic or present as

classic pertussis

Adults may describe intermittent

Older persons often source of infection for

children

PERTUSSIS – TREATMENT

Azithromycin – 5 days (most effective/common)

Erythromycin – 14 days (7-14 days infants ≥6

months & children)

Clarithromycin – 7 days (not recommended for

< 1 month of age)

Bactrim/Septra – 10-14 days

Post-exposure prophylaxis (PEP)

is

SAME AS TREATMENT.

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Month - Year

Pertussis Cases by Episode Month, 2009-2019 YTD

* CDC week year used, which may differ from calendar year totals

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services on 3/1/19

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San Diego County Number of Pertussis Cases Reported by Age Group, 2019 (N=73).

<6mos 6mos-3yrs 4-6yrs 7-9yrs 10-17yrs 18-64yrs 65+



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San Diego County Number of Pertussis Cases Reported by Race/Ethnicity and Age Group, 2019 (N=73).

Other/Unknown White Hispanic or Latino Asian Black or African American



*Rate per 100,000 population using SANDAG population estimates for 2016


PERTUSSIS

WHAT CAN YOU DO?

Consider pertussis in any patient with classic presentations,

persistent cough, or cough complaints out of proportion to

exam

Recognize the challenge of diagnosis in young infants

Encourage all patients to be up-to-date with pertussis

vaccination, especially pregnant women!

Presumptive treatment is cost effective, but test when infants

and/or pregnant women are in the household and when

outbreaks are suspected to facilitate public health actions.

PRIORITY CONTROL STRATEGY EVERY PREGNANT WOMEN RECEIVES

TDAP BOOSTER FOR

EVERY PREGNANCY AT 27-36 WEEKS EGA!

VARICELLA

Image Credit: AAP

VARICELLA: CLINICAL FEATURES IN UNVACCINATED CASES

Prodrome of fever, malaise, headache, and abdominal pain 1-2 days before rash

Rash involves 3 or more successive crops over several days

Each crop usually progresses within less than 24 h from macules to papules, vesicles, pustules and crusts so that on any part of the body there are lesions in different stages of development

Rash usually starts on face and trunk, then spreads to extremities

Rash usually involves 250-500 lesions that are pruritic

Lesions are typically crusted 4-7 days after rash onset

CDC. Prevention of Varicella. MMWR 2007; 56(No. RR-4); Arvin Clin Microb Rev 1996; Vaccine 5th Edition

VARICELLA: CLINICAL FEATURES IN VACCINATED PERSONS

Breakthrough varicella: infection with wild-type varicella disease occurring > 42 days after vaccination

15-20% of one-dose vaccinated persons may develop varicella if exposed to VZV

Usually milder presentation than varicella in unvaccinated cases

Usually low or no fever

Develop < 50 lesions

Experience shorter duration of illness

Rash predominantly maculopapular rather than vesicular

25-30% of breakthrough varicella cases are not mild and have clinical features more similar to varicella in unvaccinated persons

Chaves J Infect Dis 2008; Arvin Clin Microb Rev 1996; CDC. Prevention of Varicella. MMWR 2007; 56(No. RR-4)

Image Credit: CDPH

Breakthrough Varicella

VARICELLA: COMPLICATIONS

Bacterial superinfection of skin lesions

Pneumonia (viral or bacterial)

Central nervous system manifestations (meningoencephalitis, cerebelllar ataxia)

Hepatitis, hemorrhagic complications, thrombocytopenia, nephritis occur less frequently

Increased risk for complications Adults

Immunocompromised persons

Pregnant Women

Newborns

CDC. Prevention of Varicella. MMWR 2007; 56(No. RR-4); Arvin Clin Microb Rev 19

Image Credit: CDC

Hemorrhagic Varicella

VARICELLA: TRANSMISSION

Transmitted person-to-person by direct contact, inhalation of aerosols from vesicular fluid of skin lesions of acute varicella or zoster, or aerosolized respiratory tract secretions

Incubation period: 14-16 days (range: 10-21 days)

Period of contagiousness: 1-2 days before rash onset until all lesions crusted or disappear if maculopapular rash (typically 4-7 days)

Varicella in unvaccinated persons is highly contagious (61-100% secondary household attack rate)

Varicella in one-dose vaccinated persons half as contagious as unvaccinated cases

CDC. Prevention of Varicella. MMWR 2007; 56(No. RR-4); Arvin Clin Microb Rev 1996; Seward JAMA 2004; Vaccines, 5th edition

POST-EXPOSURE PROPHYLAXIS

Varicella vaccine is recommended for use in susceptible

person after exposure to varicella

70%-100% effective if given within 72 hours of exposure

Not effective if >5 days but will produce immunity if not

infected

VariZIG ® is recommended for non-immune persons at risk

for complications

Give as soon as possible within 10 days of exposure

Very expensive

125 units/10 kg body weight up to 625 units (4 vials)


VARICELLA – MEXICO 2019 YTD




987 488

996

928

1,832

1,220

Total reported

in Mexico = 23,767

through 3/2/19

Total reported

in 6 Mexican border

states = 6,451

(27.1% of total)



http://diymaps.net/

http://diymaps.net/

http://diymaps.net/

VARICELLA – MEXICO 2018



sistema-unico-de-informacion and software on: http://diymaps.net/

5,813 2,710

5,014

3,811

9,077

7,516

Total reported

in Mexico = 128,062

Total reported

in 6 Mexican border

states = 33,941

(26.5% of total)






















http://diymaps.net/

http://diymaps.net/

http://diymaps.net/

VARICELLA – MEXICO 2018



sistema-unico-de-informacion, 2015 census data, and software on: http://diymaps.net/

175.3 95.1

141.0

129.0

177.3

218.4

Rate/100,000

in Mexico = 107.1

Rate/100,000

in 6 Mexican border

states = 159.8






















http://diymaps.net/

http://diymaps.net/

http://diymaps.net/

VARICELLA

WHAT CAN YOU DO?

Encourage routine childhood vaccination for varicella and

adult vaccination for shingles

Remember shingles is contagious to those who are non-

immune

Report varicella outbreaks, hospitalizations and deaths to

Epidemiology Program

Be aware of need for post-exposure prophylaxis in persons at

risk for severe outcome (non-immune pregnant women,

newborns, immune compromised)

MEASLES

Image Credit: CDC

Since 1/1/19, Clark County, WA has identified 73 confirmed cases

and NO suspect cases. Date of last case 3/13/19.

Ages 1 to 10 years: 53 cases

11 to 18 years: 15 cases

19 to 29 years: 1 case

30 to 39 years: 4 case

Hospitalization: 1 case

Confirmed cases include

2 cases who traveled to Hawaii

1 case who traveled to Bend, Oregon

2 cases who moved from Clark County to Georgia.

The case totals do not include confirmed cases from King County

and Multnomah County, OR

MEASLES IN WASHINGTON

Immunization status Unimmunized: 63 cases

Unverified: 7 cases

1 MMR vaccine: 3 cases

https://www.clark.wa.gov/public-health/measles-investigation

Six outbreaks (defined as 3 or more cases) have been

reported in 2019 in the following jurisdictions:

New York State, Rockland County – 147 cases

New York State, Monroe County – 7 cases

New York City – 158 cases

Washington - 73 cases

Texas – 11 cases

Illinois – 6 cases

California – 3 cases

Six cases in CA in 2019, all related to international

travel (Philippines, Ukraine)

MEASLES – UNITED STATES

http://rocklandgov.com/departments/health/measles-information/

http://rocklandgov.com/departments/health/measles-information/

https://www2.monroecounty.gov/health-index.php

https://www2.monroecounty.gov/health-index.php

https://www1.nyc.gov/site/doh/health/health-topics/measles.page

https://www1.nyc.gov/site/doh/health/health-topics/measles.page

https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/Measles/MeaslesOutbreak

https://www.dshs.texas.gov/news/updates.shtm

http://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/measles

https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/measles.aspx


https://www.cdc.gov/measles/cases-outbreaks.html

MEASLES

*Cases as of December 29, 2018. Case count is preliminary and subject to change.

**Cases as of March 14, 2019. Case count is preliminary and subject to change




REPORTED CASES OF MEASLES

SAN DIEGO COUNTY, 1985 – JANUARY 2019

3

deaths

1 death

from

SSPE

1990

Data Source: HHSA Immunizations Program

Data through January 31, 2019



Source: WHO. Downloaded 3/18/19 from: http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/

Number of measles cases reported to WHO

from member states 2/1/18 to 1/31/19

http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/



Measles case distribution by month

and WHO Region (2015-2019) 2

01

5-0

1

20

15

-02

2

01

5-0

3

20

15

-04

2

01

5-0

5

20

15

-06

2

01

5-0

7

20

15

-08

2

01

5-0

9

20

15

-10

2

01

5-1

1

20

15

-12

2

01

6-0

1

20

16

-02

2

01

6-0

3

20

16

-04

2

01

6-0

5

20

16

-06

2

01

6-0

7

20

16

-08

2

01

6-0

9

20

16

-10

2

01

6-1

1

20

16

-12

2

01

7-0

1

20

17

-02

2

01

7-0

3

20

17

-04

2

01

7-0

5

20

17

-06

2

01

7-0

7

20

17

-08

2

01

7-0

9

20

17

-10

2

01

7-1

1

20

17

-12

2

01

8-0

1

20

18

-02

2

01

8-0

3

20

18

-04

2

01

8-0

5

20

18

-06

2

01

8-0

7

20

18

-08

2

01

8-0

9

20

18

-10

2

01

8-1

1

20

18

-12

2

01

9-0

1

20

19

-02

2

01

9-0

3

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

55000

60000

65000

Month of onset

Me

asle

s ca

ses

(Lab

+Ep

i+C

linic

al)

AMR






Source: WHO. Downloaded 3/18/19 from:

Measles in Ukraine

http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en

53,218 in 2018 13,760 in 2019

0

5000

10000

15000

20

17

-02

20

17

-03

20

17

-04

20

17

-05

20

17

-06

20

17

-07

20

17

-08

20

17

-09

20

17

-10

20

17

-11

20

17

-12

20

18

-01

20

18

-02

20

18

-03

20

18

-04

20

18

-05

20

18

-06

20

18

-07

20

18

-08

20

18

-09

20

18

-10

20

18

-11

20

18

-12

20

19

-01

20

19

-02

20

19

-03

Discarded Clinical Epi

Lab Month of onset

Nu

mb

er

of

case

s

National (6-9 Y)

Cov: 67%

National (1-9 Y)

Cov: 57%

National SIA Sub-national SIA

Year Confirmed Cases

2006 945

2007 232

2008 41

2009 24

2010 42

2011 1313

2012 12744

2013 3308

2014 2326

2015 141

2016 90

2017 4782

2018 53218

2019 13760

0 2000 4000 6000 8000

10000 12000 14000

<1 year 1-4 years 5-9 years 10-14 years 15-19 years 20-29 years 30+ years

0 doses 1 dose 2+ doses Unknown

Age at onset

Nu

mb

er

of

case

s

Ukraine age distribution, vaccination status, and incidence, 2018-02 to 2019-01

0 1000 2000 3000 4000 5000 6000 7000

Inci

den

ce r

ate

per

1,0

00

,00

0

6582

4865.1 5336.1 4920.2

1548.8 1007

489.8


Source: WHO. Downloaded 3/18/19 from:

Measles in Philippines

0

1000

2000

3000

20

17

-01

20

17

-02

20

17

-03

20

17

-04

20

17

-05

20

17

-06

20

17

-07

20

17

-08

20

17

-09

20

17

-10

20

17

-11

20

17

-12

20

18

-01

20

18

-02

20

18

-03

20

18

-04

20

18

-05

20

18

-06

20

18

-07

20

18

-08

20

18

-09

20

18

-10

20

18

-11

20

18

-12

20

19

-01

20

19

-02

Discarded

Clinical

Epi

Lab Month of onset

Nu

mb

er

of

case

s

Year Confirmed

Cases

2006 216

2007 612

2008 838

2009 1351

2010 6363

2011 6519

2012 1441

2013 4855

2014 53906

2015 2021

2016 647

2017 2409

2018 20755


0

2000

4000

6000

8000

<1 year 1-4 years 5-9 years 10-14 years 15-24 years 25-39 years 40+ years

0 doses 1 dose 2+ doses Unknown

Age at onset

Nu

mb

er

of

case

s

Philippines age distribution, vaccination status, and incidence, 2018-01 to 2018-12

0

1000

2000

3000

Inci

den

ce r

ate

per

1,0

00

,00

0

2766.5

844.4

142.3 69.9 126.6 70.4 8.6

N = 20,755


Source: PAHO. Downloaded 2/4/19 from: https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=measles

-2204&alias=47518-18-january-2019-measles-epidemiological-update&Itemid=270&lang=en

Measles in Brazil

N = 10,133

https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=measles-2204&alias=47518-18-january-2019-measles-epidemiological-update&Itemid=270&lang=en
















Measles in Venezuela

727 confirmed cases in 2017 5,668 confirmed cases in 2018

40 confirmed cases in 2019

N = 9,345 Confirmed +

suspected

Source: PAHO. Downloaded 3/18/19 from: https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=measles-

2204&alias=47907-4-march-2019-measles-epidemiological-update&Itemid=270&lang=en

https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=measles-2204&alias=47907-4-march-2019-measles-epidemiological-update&Itemid=270&lang=en
















N = 241

Measles in Colombia

Source: PAHO. Downloaded 3/18/19 from: https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=measles-

2204&alias=47907-4-march-2019-measles-epidemiological-update&Itemid=270&lang=en

















Source: Secretaría de Salud. Downloaded 3/4/19 from:





Rash illness, historically childhood infection with 2-4

year epidemic cycle; most cases in winter and spring

Complications may include otitis media, pneumonia,

encephalitis, miscarriage, and death

Airborne spread - probably the most infectious

communicable disease; R0 =15-18

MEASLES - BASICS

Two doses of MMR vaccine offer >99% protection

from disease; however, requires very high population

immunity to interrupt transmission (92-95%)

No endemic transmission in the U.S. at this time –

declared eliminated in 2000

MEASLES - BASICS

COMMUNICABILITY

MEASLES CLINICAL FEATURES

Prodrome – onset 8 to 12 days after exposure

(range=7-21 days)

Stepwise increase in fever to 101º F or higher

Dry cough, coryza, conjunctivitis

Koplik spots (rash on mucous membranes)

MEASLES CLINICAL FEATURES

Rash

2-4 days after prodrome, 14 days after exposure

Maculopapular, becomes confluent (not itchy,

except late in rash)

Begins on face and head (not on face, not

measles!)

Occurs with fever

Persists 5-6 days

Fades in order of appearance

Koplik spots in mouth due to

pre-eruptive measles on day 3 of illness.

Classically described as appearing like

"grains of salt on a wet background."

KOPLIK SPOTS

Maculopapular Rashes of Childhood

Disease Cause

First measles rubeola

Second scarlet fever group A

streptococcus

Third German measles rubella

Fourth scarletina, Duke’s Same as #2

Fifth erythema infectiosa human parvovirus B19

Sixth roseola infanticum human herpesvirus 7

http://dianeatwood.com/catchinghealth/wp-content/uploads/2015/02/Boy-with-measles.jpg



MEASLES COMPLICATIONS

Condition

Diarrhea

Otitis media

Pneumonia

Encephalitis

Hospitalization

Death

Percent reported*

8

7

6

0.1

18

0.2

*Based on 1985-1992 surveillance data

Serum measles IgM antibody positive test result (may be negative in

the first 72 hours)

Significant rise in serum measles IgG antibody between acute and

convalescent titers

Isolation of measles virus from clinical samples (blood, urine or NP

secretions)

Detection of viral RNA by reverse transcription polymerase chain

reaction (RT-PCR).

ALL CASES OF SUSPECTED MEASLES SHOULD BE REPORTED

IMMEDIATELY TO THE HEALTH DEPARTMENT WITHOUT

WAITING FOR RESULTS OF DIAGNOSTIC TESTS.

MEASLES LABORATORY DIAGNOSIS

IGM AND IGG ANTIBODY RESPONSES TO ACUTE MEASLES INFECTION

Source: WHO

MEASLES

TREATMENT

No specific antiviral

treatment available

Vitamin A once daily for 2

days – World Health

Organization (WHO)

recommends for all

children with acute

measles, regardless of

their country of residence.

Supportive

POST-EXPOSURE

PROPHYLAXIS

MMR vaccine may be given <72 hours of

exposure to persons ≥6 months of age

with 1 or no documented doses of MMR,

if not contraindicated.

Immune globulin (IG) may be given to

exposed susceptible people* of any age

≤6 days of exposure to prevent infection

(* = infants <12 months, pregnant women

without evidence of measles immunity,

severely immunocompromised persons.)

CALL COUNTY!

Infectious Period: 4 days before rash onset through 4 days

after rash onset (day of rash onset is day 0)

Incubation Period: 8-12 days after exposure (day 0) and rash

onset is typically 14 days (range 7-21 days) after exposure

Exposure: sharing the same airspace with an infectious person

(during the 4 days prior through the 4 days after rash onset) =

same classroom, home, clinic waiting room, airplane, store,

etc. up to 2 hours after the person was present.

KNOW THE IMMUNE STATUS OF ALL STAFF NOW!!!

MEASLES – INFECTION CONTROL

MEASLES – OUTREACH

MEASLES – WHAT CAN YOU DO?

IDENTIFY ISOLATE INFORM

Maintain a high index of suspicion in appropriate cases

Fever + rash

Travel history

Know the immune status of all your staff – NOW!!!

Contact the LHD when suspected, not confirmed

Urine PCR is an ideal test when available (can get thru

San Diego PHL )

3 C’s and Koplik spots

Exposure to travelers

KAWASAKI DISEASE

Image Credit: Kawasaki Foundation

For more information contact:

Eric C. McDonald, MD, MPH, FACEP Medical Director, Epidemiology and Immunizations Services

Public Health Services

County of San Diego Health and Human Services Agency

3851 Rosecrans Street (MS-P578)

San Diego, CA 92110

Phone: (619) 692-8436

Fax: (858) 715-6458

Email: [email protected]

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